Activity Development Planning Committee
Please note that all disclosure information must be current within 12 months of the start of the activity before submission of this form.
Administrative Staff Contact
Planning Committee Chair
Activity Planning Committee Member
Provide at least two data sources used to identify the educational need or clinical practice gap described above. For the data source chosen, provide a brief description of the source and the data. C2
Educational Objectives C2
If yes, please describe the type of support and the anticipated amount if available:
Other Anticipated Financial Support
Based on the outcome determined above (competence, performance or patient outcomes), indicate the evaluation method used to analyze changes in learners achieved as a result of the program's activities/educational interventions.